PATIENT INFORMATION
Last Name:___________________________ First Name:__________________________ M.I.________
DOB: _____________ Age: ________ SSN: ________________________ Gender: M [ ] F [ ]
Mailing Address: _________________________________________
City, State, Zip: ____________________
Physical Address:_________________________________________
City, State, Zip: ____________________
Home Ph#: _____________________ Cell Ph#: ____________________ Reminders: Text [] Call [] Email []
I authorize this organization to leave a message on my voicemail Y[ ] N[ ] Home[] Cell[] Work []
Email Address:________________________________ Marital Status M [ ] S [ ] D [ ] W [ ]
Employed: Y [ ] N[ ] If yes, Employer Name: ____________________________
Work Ph#: _______________ Occupation/Title: _________________________
Retired: Y [ ] N [ ] Student: Y [ ] N [ ]
PHYSICIAN REFERRAL INFORMATION
Primary Care Doctor: __________________ Referring Physician: ________________________
INSURANCE/BILLING INFORMATION
Primary Insurance: __________________________Primary Insured: _________________________
DOB of Insured:_______________ ID#: _____________________________ Group#:_____________________
Secondary Insurance: _______________________ Secondary Insured: ______________________
DOB of Insured: ______________ ID#: ________________________________
Group#: _________________
If you have Medicare and a private insurance, does your employer have more than 20 employees: Y[] N[]
Responsible Party:___________________________________ D.O.B.______________
SSN: ____________________ Relationship to Patient: ___________________________________
EMERGENCY CONTACT INFORMATION
Emergency Contact: _________________________ Relationship: _______________ Phone#: ______________ Emergency Contact: _________________________ Relationship: _______________ Phone#: ______________ I authorize this organization to discuss my condition with the persons listed above. Y [ ] N [ ]
I authorize the release of any medical or other information necessary to process my claims. I also request payment of government benefits either to myself or to the party physician or supplier for services described, who accepts assignment. I authorize payment of medical benefits to the claim.
__________________________________________ __________________________
Signature Date
HIPAA PRIVACY ACT
AUTHORIZATION TO RECEIVE/RELEASE HEALTH INFORMATION
Due to the HIPAA Compliance Privacy Laws of the Federal Government, it is mandatory that we ask you to review and answer the following questions listed below.
NAME: __________________________________ D.O.B: _______________ Pt. Acct#_______
May we leave messages with detailed medical information (including billing information) on voicemail at either of your home or cell phone? Y [ ] N [ ] Cell _________________ Home___________________
May we contact your place of employment? Y[] N[] If so, may we leave a message? Y[] N[]
Work #___________________ Ext: ____
Do you have any particular person or family members that you authorize to receive and discuss information regarding your personal health information (general, surgical and billing information)? Y [ ] N [ ]
If yes, please provide:
Name ____________________________ Relationship____________ Phone #_____________
Name ____________________________ Relationship____________ Phone #_____________
Are any of these people your Power of Attorney for medical purposes? Y [ ] N [ ]
I authorize the release of my medical records to other Physicians/HealthCare providers Y [ ] N [ ]
Referring Physician: _________________________ Medical Doctor: ________________________
Other Physicians: __________________________ ___________________________
I hereby authorize HD Retina Eye Center Ltd. to obtain or release any and all pertinent information regarding my medical care, as needed, to assist in my ongoing treatment or from other health care providers, laboratories, radiology facilities or other institutions. This authorization remains in effect until revoked.
I have reviewed the aforementioned information and provide my consent regarding any and all issues as stated above.
I acknowledge that I have read, understand and been offered a copy of the HD Retina Center Ltd Notice of Privacy Practices. I have reviewed HD Retina Eye Center Ltd. Notice of HIPAA Privacy Policy (A copy of this policy will be provided to me upon request.)
NONDISCRIMINATION STATEMENT
Nondiscrimination statement for significant publications and signification communications that are small-size:
HD Retina Eye Center complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex.
____________________________ ______________________
Signature (patient or parent if minor) Date
_____________________________
Witness (Staff Signature)
ASSIGNMENT OF INSURANCE BENEFITS
I request that any authorized benefit payments on my behalf, from Medicare or any other insurance company, be made directly to HD Retina Eye Center for any services furnished to me by the rendering service provider who accepts assignments. I understand that regulations pertaining to Medicare assignment of benefits apply. I authorize release of pertinent medical or other information about me to the Social Security Administration and Health Care Financing Administration or its intermediaries or carrier or any other insurance company needed in order to process this or a related Medicare/Other Insurance Company claim.
I also understand that in Medicare/Other Insurance assigned cases, the physician or supplier agrees to accept the charge determination of the Medicare/Other Insurance company as the full charge, and the patient is responsible only for the deductible, coinsurance, and non-covered services. Coinsurance and the deductible are based upon the charge determination of the Medicare/Other Insurance Company.
I am aware the HD Retina Eye Center Ltd is not responsible for any incorrect insurance information or absence of referrals. I understand that I am responsible for payment of services performed if HD Retina Eye Center Ltd does not have the proper insurance information or if a primary care physician referral (if required by your medical insurance) is not made, or I may be subject to rescheduling my exam if the needed referral is not received.
I understand there is a cancelation fee of $25 for an office visit or a $50 fee for a procedure, if I miss my appointment and
do not provide more than 24-hour notice.
I understand that I am financially responsible for ALL charges WHETHER OR NOT paid by my insurance. I hereby authorize release of any information needed to secure payment.
_______________________________________________ ___________________________
Name of Patient/Guardian Date
_______________________________________________
Signature of patient/guardian
MEDICAL HISTORY FORM
Name: ________________________________________DOB_____________ Pt Acct# (staff will fill in)________
What problem are you seeing us for? _________________________________________________________
___________________________________________________________________________________
When did your problem start? ______________________________________
Who referred you to us? _________________________
Primary Care Doctor: _________________________
Previous Eye History/Surgeries:
_____________________________________________________________________________________
_____________________________________________________________________________________
Are you experiencing any of the following:
Right Eye: [ ]Blurred vision [ ]Loss of vision [ ]Flashes and/or Floaters [ ]Shadows [ ]Eye Pain [ ]Lazy Eye
Left Eye: [ ]Blurred vision [ ]Loss of vision [ ]Flashes and/or Floaters [ ]Shadows [ ]Eye Pain [ ]Lazy Eye
Review of Systems:
HEENT:
[ ] Hearing Loss [ ] Scalp Tenderness [ ] Hoarseness [ ] Chronic Cough [ ] Bloody Sputum [ ] Jaw Pain
Respiratory:
[ ] Cough TB [ ] Wheezing [ ] Shortness of Breath [ ] Asthma [ ] Use of Oxygen
Neurological:
[ ] Headaches [ ] Seizures [ ] Focal weakness [ ] Numbness [ ]Balance Problems [ ] Trouble Walking [ ] Stroke
GI System:
[ ] Abdominal Pain [ ] Nausea [ ] Diarrhea
Cardiovascular:
[ ] ChestPain [ ] IrregularHeartBeat [ ]Heart attack [ ] Congestive Heart failure [ ] Pace maker
Cancer:
Please specify which type, where, and indicate if you received surgery, chemotherapy, radiation therapy, or hormone therapy:__________________________________________________________________
________________________________________________________________________
General:
[ ] Diabetes [ ] High blood pressure [ ] Bruise easily [ ] Hepatitis [ ] HIV
[ ] Excessive Thirst [ ] Excessive Urination [ ] Intolerance to Hot/Cold
Current Medication list: Please list all medications you are currently taking (include strength/dosage and how many per day or provide separate list):
1.___________________ 2.___________________ 3.___________________ 4. ____________________
5.___________________6.____________________7.___________________8._____________________
9.____________________10.__________________11.__________________12.____________________
Do you have any seasonal allergies and/ or medication allergies? If yes, please list:
____________________________________________________________________________________
PAST MEDICAL HISTORY—please includes diagnoses and dates of onset
List SURGERIES and HOSPITALIZATIONS—please include approximate dates:
Social History:
Living Conditions: Y N Live alone? Y N Live with Family? Y N Live with Friends?
Do you currently smoke or use tobacco? Y N If yes, how much? _________________________________
Have you ever smoked or used tobacco? Y N If Yes, when did you quit? _________ _________________
Do you drink alcohol? Y N If yes, how much? _________________________________________
Do you consume caffeine? Y N If yes, how much? ______________________________________
Do you use any other recreational substances? Y N If yes, which substances? How much _______________________
Occupation:
In Hospice? Y N
Family History of eye problems: (please circle)
Diabetes Cataracts Glaucoma Macular Degeneration Blindness Lazy eye/eye turn
AUTHORIZATION FOR TREATMENT
I hereby authorize the physicians of the HD Retina Eye Center LTD to render medical and surgical treatment for my condition (s) as determined medically necessary.
______________________________________
Patient’s Printed Name
______________________________________ _____________________
Patient Signature Date
______________________________________ _____________________
Witness Name and Signature Date
INFORMATION REGARDING DILATING DROPS
Dilating drops are used to dilate or enlarge the pupils of the eye to allow the ophthalmologist to get a better view of the inside of your eye.
Dilating drops frequently blur vision for a length of time which varies from person to person and may make bright lights bothersome. It is not possible for your ophthalmologist to predict how much your vision will be affected. Because driving may be difficult immediately after an examination, it is recommended that you have a driver.
Adverse reaction such as acute angle-closure glaucoma may be triggered from the dilating drops. This is extremely rare and treatable with immediate medical attention.
Authorization for Use of Dilating Drops
I hereby authorize the physicians or HD Retina Eye Center and/or such assistants as may be designated by him/her to administer dilating eye drops. I understand that the eye drops are necessary to diagnose my condition. This authorization remains in effect for every office visit I may incur where dilation is necessary, unless revoked by me in writing.
____________________________________________
Patient’s Printed Name
____________________________________________ ___________________
Patient’s Signature Date
__________________________________________ ___________________
Witness Name & Signature Date
CONSENT FOR PHOTOGRAPHY
I, __________________________________ hereby authorize Dr. Hardeep Dhindsa and associates to take photographs, slides, and or light digital imaging appropriate to my procedure. I understand this imaging is important in the diagnosis and possible treatment of my condition.
I further authorize Dr. Hardeep Dhindsa and associates to use the photographs slides, and or imaging for professional medical purposes, while maintaining my confidentiality. Professional medical purposes include but are not limited to showing the photos, slides, and or imaging on all electronic media, or using the photographs, slides and or imaging for purposes of medical publication, medical education, or during lectures to medical or la y groups, and for use in medical examination.
_____________________________________
Name of Patient/ guardian
_____________________________________ ___________________
Signature of Patient/guardian Date